Methods and systems for disease management care coordination

ABSTRACT

Methods and systems for disease management care coordination are described. In one embodiment, claim data associated with a prescription drug is integrated with additional health data from a plurality of data feeds received from a client device, a care coordination device, and a health management vendor device. The integrated data is targeted to identify a member. The integrated data associated with the member is transmitted to a patient evaluator device. The integrated data is updated using additional member information received from the patient evaluator device. Other methods and systems are described.

RELATED APPLICATION

This disclosure claims priority to U.S. Provisional Patent ApplicationNo. 61/435,217, entitled “Methods and Systems for Disease ManagementCare Coordination,” filed on Jan. 21, 2011, herein incorporated byreference in its entirety.

FIELD

The present disclosure generally relates to care coordination, and moreparticularly disease management care coordination.

BACKGROUND

It is not uncommon for more than one healthcare provider or vendor toprovide healthcare to an individual. The many different entities maycollect, utilize, and internally maintain information associated with amember to provide them with the appropriate care. Information about amember may include the medical history of the member, demographicinformation, medication history and allergies, and claims information.As the different vendors and providers may not even be aware that themember is receiving care from other vendors or providers, the variousvendors and providers may each maintain records regarding the treatmentof the individual, which may include partial or incomplete information.

BRIEF SUMMARY

FIG. 1 is a block diagram of an example disease management carecoordination system, according to an example embodiment;

FIGS. 2-4 are block diagrams that illustrate example relationships,according to example embodiments;

FIG. 5 illustrates an example care coordination device that may bedeployed in the system of FIG. 1, according to an example embodiment;

FIG. 6 illustrates an example patient evaluator device that may bedeployed in the system of FIG. 1, according to an example embodiment;

FIG. 7 illustrates an example client device that may be deployed in thesystem of FIG. 1, according to an example embodiment;

FIG. 8 is a block diagram of an example care coordination subsystem thatmay be deployed with the care coordination device of FIG. 5, the patientevaluator device of FIG. 6, and/or the client device of FIG. 7,according to example embodiments;

FIG. 9 is an example process flow illustrating a method for carecoordination, according to an example embodiment;

FIGS. 10-17 are example displays, according to example embodiments; and

FIG. 18 is a block diagram of a machine in the example form of acomputer system within which a set of instructions for causing themachine to perform any one or more of the methodologies discussed hereinmay be executed.

DETAILED DESCRIPTION

Example methods and systems for disease management care coordination aredescribed. In the following description, for purposes of explanation,numerous specific details are set forth in order to provide a thoroughunderstanding of example embodiments. It will be evident, however, toone of ordinary skill in the art that embodiments of the invention maybe practiced without these specific details.

In an embodiment, a disease management care coordination system mayfacilitate sharing information associated with members among differenthealthcare providers, care coordinators, and clients, which may allow ahealthcare coordinator and its partners to work in a best practiceenvironment. The targeting may include a number of queries that may bedefined (e.g., by a clinician). Targeting may then be used to identifymembers according to different attributes. Attributes may include, butare not limited to, disease states, geographic location, medicationreceived, type of health insurance, or other type of informationassociated with members.

The disease management care coordination system may reduce the barriersrequired to make better pharmacy intervention that may lead to bettermember outcomes. A care coordination system, according to an embodiment,may contain cases of a member population of a client generated bytargeting by a healthcare coordinator. The system may provide access tothe latest information available for members to target generated casesand pharmacy claims as well as the ability to document clinicalintervention outcomes.

The methods and systems may be used to address fragmented care or thegap between the health care providers and vendors. A care coordinatormay offer an integrated portfolio of services and tools to identify drugprograms within a specific member population. Patient evaluators (e.g.,nurses), may use the services and tools to identify members for outreach(e.g., members with problem cases), research the cases, obtainadditional information from the care coordinator on the medications, andtake action with the member in an attempt to improve the health of themember.

A disease management care coordination system may be used in ahealthcare setting that provides a platform to integrate a healthcarecoordinator with clients and vendors to improve member case management.The care coordination system may be a web-based system.

The disease management care coordination system may be used to organizeinformation to enable providing of drug information and reviewing ofmember cases so that health management vendors can better utilize timemaking outreaches work.

In some embodiments, the methods and systems make prescription drugssafer and more affordable. In some embodiments, the use of the methodsand system may reduce or eliminate the number of reports regarding casesof members provided by the care coordinator to a disease managementgroup or client. In some embodiments, the methods and system may reducethe administrative burden of communicating with members regarding healthissues. In some embodiments, the methods and systems may reduceduplicative communication of the members by both health careprofessionals and patient evaluators.

FIG. 1 is a block diagram of an example system 100, according to anexample embodiment. The system 100 includes a client device 102 by whicha client may communicate over a network 104 with a care coordinationdevice 106, a patient evaluator device 108, and/or a health managementvendor device 142.

Generally, a client engages a pharmacy benefit manager (PBM) to offer adrug benefit program. Examples of clients include governmentalorganizations (e.g., Federal government agencies, the Department ofDefense, the Centers for Medicare and Medicaid Services and stategovernment agencies), middle market companies, large national employers,health insurance companies that have carved out the drug benefit, andthe like. The PBM may be a stand-alone PBM, or may be part of a largerorganization that offers other benefits or services.

The client device 102 may be used by a client to maintain memberinformation and receive reports from the care coordinator. The clientmay be an organization that engages the services of the carecoordinator.

The client may be an employer group or health management vendor actingon behalf of the employer group (e.g., healthcare management vendor,such as a disease management vendor). Examples of employer groupsinclude Boeing, Anheuser Busch Inbev, FedEx, and the like. An employergroup may be a company, corporation, or similar entity that employsindividuals but do not have the clinical abilities to provide healthcarefor the individuals. The employer group may outsource clinical and otherhealth care services for the group to another entity, such as a healthmanagement vendor (e.g., disease management vendor). Thus, the employergroup hires patient evaluators to communicate with the members (e.g.,employees) of the employer group regarding disease management. In someembodiments, the patient evaluators are associated with multiple healthmanagement vendors. The patient evaluators may be hired by (or otherwisework for) the employer group, or may be hired by the medical providerassociated with the employer group. The healthcare coordinator maycommunicate with the one or more health management vendors on behalf ofthe client through vendor-to-vendor communications and may ensure thatmember issues, such as pharmacy issues, are addressed on behalf of theclient.

The client may be a health plan that has its own patient evaluators oroutsources the function of the patient evaluator. The health plan mayprovide medical services, pharmacy services, or both medical andpharmacy services. The health plan may have an internal or externalsource of patient evaluators. In some embodiments, health plans may notneed to outsource the healthcare responsibilities to a health managementvendor, but may be able to coordinate much of the healthcare needsinternally.

A healthcare coordinator or care coordinator may be a vendor thatfacilitates communication between the various healthcare entities, suchas the client, health management vendors, members, and other healthcareproviders.

A health management vendor may be a vendor who receives claims data andreview member claims to identify health improvement opportunities.

The reports received may document the success that the patientevaluators have had in working with the members of the client.

Examples of the network 104 by which the client device 102 maycommunicate with the care coordination device 106, the patient evaluatordevice 108, and/or health management vendor device 142 include MobileCommunications (GSM) network, a code division multiple access (CDMA)network, 3rd Generation Partnership Project (3GPP), an Internet Protocol(IP) network, a Wireless Application Protocol (WAP) network, a Wi-Finetwork, or an IEEE 802.11 standards network, as well as variouscombinations thereof. Other conventional and/or later developed wiredand wireless networks may also be used.

The care coordination device 106 may be used to access a diseasemanagement care coordination subsystem, discussed below. The carecoordination device 106 is maintained by, or on behalf of, a carecoordination organization.

The care coordinator coordinates care with the patient evaluators andthe client (or entity acting on behalf of the client) to make sure thatpharmacy issues of the members of the client are addressed.

The care coordinator and the patient evaluators may be in regular and/orperiodic communication, but the ultimate results in the form of a reportthat may be provided to the client. The results may be provided to theclient monthly, quarterly, annually, in real-time, or at otherfrequencies. In some embodiments, the results may reflect that themembers are healthier as a result of the coordination of care betweenthe care coordinator and the patient evaluators. When the client is ahealth management vendor (e.g., disease management group) acting onbehalf of an employer group, the results may be provided to the healthmanagement vendor, the employer group, or both. An example of a companythat provides care coordination services is Express Scripts, Inc. of St.Louis, Mo.

The patient evaluator device 108 is used by patient evaluators access adisease management care coordination subsystem, discussed below. Thepatient evaluators may use the computerized tool to provide better careand encourage healthy behavior among the members of the client.

The patient evaluators may be associated with a health management vendor(e.g., disease management group). For example, the employer group mayhire a particular disease management group to talk to members of theemployer group regarding disease management.

The health management vendor device 142 is used by health managementvendors to access the disease management care coordination subsystem,discussed below, to maintain data about the members and coordinate care.The health management vendors may use the disease management carecoordination subsystem, discussed below, to provide treatment to membersand to communicate with healthcare partners, such as the clients,patient evaluators, and care coordinators, to gain a more comprehensivepatient profile.

While patient evaluators may include nurses, other persons that may bepatient evaluators include, but are not limited to, doctors andpharmacists. In some embodiments, the doctors and/or nurses may beassociated with a clinic.

Examples of organizations that provide patient evaluators include CIGNA,Aetna, Anthem, and the like. The patient evaluators may also be internalto a health group. The patient evaluators may contact members for avariety of reasons including medical and/or pharmaceutical reasons.

The care coordinator may provide consultation (e.g., pharmaceuticalconsultation) to patient evaluators. The patient evaluators may use thereceived information when determining an action to take with respect toa member.

In some embodiments, the client device 102 and the patient evaluatordevice 108 are operated by a single entity. In other embodiments, theclient device 102 and the patient evaluator device 108 are operated bydifferent entities. In some embodiments, the client device 102 and thepatient evaluator device 108 are combined into a single server. In someembodiments, the client device 102 and the patient evaluator device 108operate on separate servers.

The disease management care coordination system may be implemented as astand-alone device that solely provides at least some of thefunctionality to enable disease management care coordination, or may bea multi-use device that has functionality disease management carecoordination as described herein. In some embodiments, the device may bea mobile device, a portable device, or a stationary computing device.

Examples of the devices 102, 106, 108, 146 include a gaming unit, amobile phone, a personal digital assistant (PDA), a display device, ageneric or specialized computing system, or the like. Other devices mayalso be used. The devices 102, 106, 108, 146 may each use the same typeof device, or may use different types of devices.

The system 100 may further include a client database 110, a carecoordinator database 112, a patient evaluator database 124, a healthmanagement vendor database 128, and/or a care coordinator integrateddatabase 132.

The health management vendor device 142 may be in communication with ahealth management vendor database 128. The health management vendordatabase 128 may store health management vendor data 130. Healthmanagement vendor data 130 may include pharmacy claims data 116 andmedical claims data 116 that may be used to identify health improvementopportunities.

The client device 102 may be in communication with a client database110. The client database 110 may store member data 114 of the members ofthe client. Member data 114 may include demographic data, contactinformation, health insurance data, and other types of personal dataassociated with members.

The care coordination device 106 may be in communication with a carecoordination database 112. The care coordination database 112 may storedata used to coordinate care for the member. The data that may be storedin the care coordination database 112 includes the member data 114obtained by the care coordination device 106, claims data 116 detailingthe claims of the members, targeting data 118, coordination data 120storing the various actions taken by the patient evaluator, and thetrigger data 122. The claims data 116 may include prescription claimhistory of the members of the client. The targeting data 118 mayincludes a number of queries that may be defined (e.g., by a clinician).The targeting data 118 may be used by the disease management carecoordination system to identify members. The coordination data 120 mayinclude data that documents member outcomes. An outcome may be a resultof an interaction or response to a therapy prescribed to the member. Thecoordination data 120 may include interventions, case history, and thelike. The trigger data 122 may include data used by the diseasemanagement care coordination system 100 to identify problem areasassociated with members, such as queries. Trigger data 122 may be aquery, rule, policies, or similar method of information retrieval thatmay include inclusive and exclusive criteria to identify patients. Thecriteria that may be used to identify patients may include any type ofmember attribute. For example, a higher dollar spend on medication,members with multiple open cases, and the like may be identified throughuse of the trigger data 122.

The patient evaluator device 108 may be in communication with a patientevaluator database 124. The patient evaluator database 124 may storepatient evaluation data 126 of the members of the client. The patientevaluation data 126 may include labs results, notes by the patientevaluator regarding treatment of the member, member outcomes, or otherinformation that may be derived from the interaction between the patientevaluator and the member.

The care coordination device 106 may be connected with the carecoordination integrated database 132 to access and update the integrateddata 134 of members, generate various levels of reports, and provide oneor more data feeds of the integrated data 134 to users of the system100. The users of the system may include the client, health managementvendor, patient evaluators, and other medical service providers.

Data feeds from devices 102, 106, 108, 142 and databases 110, 112, 124,128 may be integrated and stored as integrated data 134 in a carecoordinator integrated database 132. The integrated database may storedata received from various healthcare providers, vendors, and clients tointegrate and compile comprehensive data associated with members. Theintegrated data 134 may include patient profiles compiled from datareceived from client devices 102, care coordination devices 106, healthmanagement vendor devices 142, and/or patient evaluator devices 108. Theintegrated data 134 may be integrated based upon member identification.In some embodiments, the integrated data 134 may be integrated basedupon a combination of information used to identify a member, such asinsurance policy number, home address, contact number, or any similarinformation.

While the system 100 in FIG. 1 is shown to include single devices 102,106, 108, 142 multiple devices may be used. The devices 102, 106, 108,142 may be the same type of device or may be different device types.When multiple devices are present, the multiple devices may be of thesame device type or may be a different device type. Moreover, system 100shows a single network 104; however, multiple networks can be used. Themultiple networks may communicate in series with each other to link thedevices 102, 106, 108, 142 or in parallel to link the devices 102, 106,108, 142.

FIGS. 2-4 are block diagrams showing example relationships betweenvarious people associated with the system 100. Other types ofrelationships and different people may be engaged with the system 100beyond these example relationships.

Relationship 200, depicted in FIG. 2, reflects when a client 202 may bean organization that does not have the clinical abilities to providehealthcare for members 212. Thus, the client may hire one or more healthmanagement vendors 206 to provide healthcare for members 212 associatedwith the client 202. As shown, the client 202 contracts with a carecoordinator 204 to provide coordination of care services for members 212of the client 202 through access to a disease management carecoordination system. The members 212 may be employees of the client 202.

The health management vendor 206 that contacts the members 212 of theclient 202 may be a disease management vendor. Patient evaluators 208(e.g., nurses, doctors, or other people) may contact the members 212 toprovide health care. The patient evaluators 208 may contact health careprofessionals 210 (e.g., pharmacists) to obtain additional informationthat may be used to provide heath care services for members 212.

Members 212 may be employees of the client 202 or otherwise associatedwith the client 202 and have received some type of medical and/orpharmaceutical benefit through a health plan associated with the client202.

Relationship 300, depicted in FIG. 3, depicts when the client 202 mayhave its own patient evaluators 208 and thus does not use a healthmanagement vendor 206. For example, a health care organization that hasa health plan may engage the care coordinator 204 to obtain access tothe care coordination subsystem 502.

Relationship 400, depicted in FIG. 4, depicts when there are multiplepatient evaluators associated with the health management vendor 206(e.g., disease management vendor) (or directly with the client 202). Insome embodiments, a patient evaluator manager 402 manages the case loadof various patient evaluators 404-408. Patient evaluator manager 402 mayreceive identified cases of members 212 and assign the cases to patientevaluators 404, 406, 408.

FIG. 5 illustrates the care coordination device 106, according to anexample embodiment. The care coordination device 106 may include a carecoordination subsystem 502. The care coordination subsystem 502 may be acomputerized tool that enables the patient evaluators 208 to efficientlymanage cases of the members 212. Through use of the care coordinationsubsystem 502, the patient evaluators 208 may have more informationabout the member available faster. Thus, the patient evaluators 208 maybe able to provide better care to members 212 through use of the carecoordination subsystem 502.

The care coordination subsystem 502 may have all the functionality onthe care coordination device 106, some of the functionality on the carecoordination device 106 and other devices (e.g., 102, 108, 142), or allthe functionality on other devices 102, 108, 142. The care coordinationsubsystem may be implemented as a think client, a thick client,peer-to-peer or otherwise. In some embodiments, access to the carecoordination subsystem may be based on the role of the person accessingthe care coordination subsystem 502.

The care coordination device 106 with the care coordination subsystem502 may be deployed in the system 100, or may be deployed in anothersystem.

FIG. 6 illustrates the patient evaluator device 108, according to anexample embodiment. The patient evaluator device 108 includes a carecoordination subsystem 502. The patient evaluator device 108 with thecare coordination subsystem 502 may be deployed in the system 100, ormay be deployed in another system.

FIG. 7 illustrates the client device 102, according to an exampleembodiment. The client device 102 includes a care coordination subsystem502. The client device 102 with the care coordination subsystem 502 maybe deployed in the system 100, or may be deployed in another system.

In some embodiments, the system 100 may include a health managementvendor device 108 which may include a care coordination subsystem 502.The health management vendor device 108 with the care coordinationsubsystem 502 may be deployed in the system 100, or may be deployed inanother system.

FIG. 8 illustrates an example disease management care coordinationsubsystem 502 that may be deployed in the client device 102, carecoordination device 106, patient evaluator device 108, health managementvendor device 142, or otherwise deployed in another system. One or moremodules are communicatively coupled and included in the diseasemanagement care coordination subsystem 502 to enable disease managementcare coordination. The modules of the disease management carecoordination subsystem 502 that may be included are a targeting module802, a request receiver module 804, an interface module 806, a dataaccess module 808, an allocation module 810, a tracking module 812, areporting module 814, an integration module 816, an integrated datatransmission module 818, an integrated data update module 820, atransmission module 822, and/or a data feed module 824. Other modulesmay also be included. In some embodiments, the care coordinationsubsystem 502 may be a web-based tool.

In some embodiments, the modules of the disease management carecoordination subsystem 502 may be distributed so that some of themodules are deployed in care coordination device 106 and some modules inthe patient evaluator device 108 and/or health management vendor device142. In one embodiment, the modules are deployed in memory and executedby a processor coupled to the memory. The functionality contained withinthe modules 802-824 may be combined into a lesser number of modules,further divided among a greater number of modules, or redistributedamong existing modules. Other configurations including the functionalityof the modules 802-824 may be used.

In some embodiments, the care coordination subsystem 502 may be a closedtool, requiring users of the system to access the subsystem 502 using acare coordination subsystem client (not shown). One or more modules maybe communicatively coupled and included in the care coordinationsubsystem 502 to enable coordination of care of a member.

In some embodiments, the modules of the care coordination subsystem 502may be distributed so that the modules are deployed in one or more ofthe client device 102, the care coordination device 106, the patientevaluator device 108, and health management vendor device 142. In oneembodiment, the modules are deployed in memory and executed by aprocessor coupled to the memory.

The care coordination subsystem 502 may be used by the patientevaluators 208 to prioritize cases for providing health care services.The prioritization may enable the patient evaluators 208 to focus ongiving better care.

The health care services provided by the patient evaluators 208 maydrive behavior changes to improve health of the members 212.

In some embodiments, the care coordination subsystem 502 is implementedas a care coordination tool by which the patient evaluators 208 mayaccess through their patient evaluator devices 108. At least a portionof the functionality of the care coordination subsystem 502 may beimplemented within the care coordination device 106.

The targeting module 802 may run targeting on the claims data 116 usingthe targeting data 120. The targeting may be run weekly or with adifferent frequency to identify cases. The targeting may include anumber of queries that may be defined (e.g., by a clinician). Targetingmay then be used to identify members 212 according to differentattributes. Attributes may include, but are not limited to, diseasestates, geographic location, medication received, type of healthinsurance, or other type of information associated with members.

The targeting may not be immediately run to enable time for changes tothe claims data 116 due to error or other problems. In some embodiments,by running the targeting on the claims data 116 that is recent, thepatient evaluator 208 can have access to timely information about themembers 212. In some embodiments, providing more timely information tothe patient evaluator 208 provides a greater chance that the member 212will be receptive to or otherwise adopt the information and/or adviceprovided by the patient evaluator 208.

Examples of results of targeting include identifying members 212 who mayneed help with a first time medication, members 212 who fill aprescription late, an abnormal behavior pattern for filing aprescription by members 212, or the like.

The request receiver module 804 may receive an evaluation request. Theevaluation request may be to evaluate a case that has been identifiedthrough the targeting. In some embodiments, the evaluation request maybe to evaluate multiple cases identified through the targeting. Theevaluation request may be made prior to the patient evaluator 208contacting the member 212. The request receiver module 804 may alsogenerate a response to the received evaluation request. In someembodiments, a filter-setting request may be received by the requestreceiver module 804. Generation of the display is then based on runningthe targeting, receipt of the query request, and receipt of thefilter-setting request. The filter setting request may include a target,a disease state, or both the target and the disease state.

The interface module 806 may generate a display in response to receivinga generation request based on running the targeting and receipt of thequery request. The generated display may present information used by thepatient evaluators 208 to provide case management on behalf of themembers 212.

By way of example, if a member 212 has been newly prescribed cholesterolmedication, and the member 212 may receive a call from a patientevaluator 208 during the first week of use of the medication todetermine whether the member 212 is having any side effects based on theinformation received through the generated display by the interfacemodule 806, the member 212 is more likely to communicate with thepatient evaluator 208 then if the patient evaluator 208 contacts themember 212 six weeks after starting the new medication.

In some embodiments, the timely manner may in which the patientevaluator 208 contact the members 212 may increase the number of members212 enrolling in appropriate disease management programs.

The data access module 808 may access the trigger data 122. Generationof the display is then based on running the targeting, receipt of thequery request, and accessing the trigger data 122.

The allocation module 810 may be deployed within the care coordinationsubsystem 502 to receive a case designation and associate a case of amember 212 to a patient evaluator 208. In some embodiments, theallocation module 810 may associate the member 212 with a casedesignation responsive to the targeting. In some embodiments, theallocation module 810 may associate the member 212 with multiple casedesignations responsive to the targeting.

The tracking module 812 may be deployed within the care coordinationsubsystem 502 to receiving a case indication of a case and storing thecoordination data 122 associated with the case in the care coordinatordatabase 112 based on receipt of the case indication. In someembodiments, the tracking module 812 may receive and store theassociation of case designations and patient evaluators 208.

Reporting module 814 may generate and transmit a report over the network104. The report may be transmitted to the client device 102 or adifferent device. When deployed, the reporting module 814 generatesreports for the care coordination subsystem 502. In some embodiments,the generated reports may include a report based on the coordinationdata 122 of a single member or multiple members. The generated report onthe single member may be at an operational level report. The generatedreport on multiple members may be at a summary level report. The summarylevel report may include, by way of example, a number of cases that havebeen closed during a period of time. In some embodiments, the client 202may use the reports to look over months to see the trends and track theprogress of the patient evaluators. In some embodiments, the reportsgenerated by the reporting module 814 include an outcomes report. Theoutcomes reports includes activity done based on the program mayidentify downstream impact of the coordination of care. The outcomesreport may reveal whether the rates of hospitalizations were reduced forthe members.

An integration module 816 deployed within the care coordinationsubsystem 502 integrates data from multiple data feeds received from aclient device 102, a care coordination device 106, patient evaluatordevice 108, and/or health management vendor device 162.

The data feed from the client device 102 may include member data 114 mayinclude demographic data, contact information, health insurance data,and other types of personal data associated with members. Member data114 may be retrieved from the client database 110.

The data feed from the care coordination device 106 may include themember data 114 obtained by the care coordinator, claims data 116detailing the claims of the members, targeting data 118, coordinationdata 120 storing the various actions taken by the patient evaluator, andthe trigger data 122. The claims data 116 may include prescription claimhistory of the members of the client. The targeting data 118 mayincludes a number of queries that may be defined (e.g., by a clinician).The targeting data 118 may be used by the disease management carecoordination system to identify members. The coordination data 120 mayinclude data that documents outcome. The coordination data 120 mayinclude interventions, case history, and the like. The trigger data 122may include data used by the disease management care coordination system100 to identify problem areas associated with members, such as queries.

The data feed from the patient evaluation device 108 may include patientevaluation data 128 or health data which may include labs results, notesby the patient evaluator regarding treatment of the member, memberoutcomes, or other information that may be derived from the interactionbetween the patient evaluator and the member.

An integrated data transmission module 818 may be deployed within thecare coordination subsystem 502 to transmit the integrated dataassociated with a member 212 to a patient evaluator device 108.

An integrated data update module 820 may be deployed within the carecoordination subsystem 502 to update the integrated data 134 usingadditional member information received from the patient evaluator 208.The additional information may include lab results, clinical notes,outcomes from member interactions, or other data that may be derivedfrom the interaction between the patient evaluator and the member. Insome embodiments, the integrated data update module may update theintegrated data 134 using information received from other medicalservices providers, such as pharmacists or specialists (e.g., diseasespecialist).

A transmission module 822 may be deployed within the care coordinationsubsystem 502 to transmit a patient profile to a medical servicesprovider. The patient profile may include trigger data 122 and theintegrated data associated with the member.

A data feed module 824 may be deployed within the care coordinationsubsystem 502 to transmit or otherwise provide a data feed of theintegrated data 134.

Data feeds from devices 102, 106, 108, 142 and databases 110, 112, 124,128 may be integrated and stored as integrated data 134 in a carecoordinator integrated database 132. The integrated database may storedata received from various healthcare providers, vendors, and clients tointegrate and compile comprehensive data associated with members. Theintegrated data 134 may include patient profiles compiled from datareceived from clients, care coordinators, and health management vendors.The integrated data 134 may be integrated based upon memberidentification. In some embodiments, the integrated data 134 may beintegrated based upon a combination of information used to identify amember, such as insurance policy number, home address, contact number,or any similar information.

FIG. 9 illustrates a method 900 for disease management care coordinationaccording to an example embodiment. The method 900 may be performed bythe care coordination device 106, partially by the care coordinationdevice 106 and partially by the client device 102 and/or the patientevaluator device 108, or may be otherwise performed.

Targeting is run on the claims data 116 at block 902 using the targetingdata 120. In some embodiments, targeting may include mining dataassociated with members 212 to identify different member opportunities.Data associated with members may include claims data 116 (e.g., pharmacyclaims data and/or medical claims data), clinical data, member data 114,lab results data, and/or data received from a wellness vendor. Targetingmay be run or executed by the care coordination device 106. Targetingmay be run or executed on a periodic basis. In some embodiments, theperiodic basis for running or executing the target data may includeallowing for reversals. Reversals occur when a claim may be reversed.Claims may be reversed for various reasons, such as the member notreceiving a prescription drug, the member returning the prescriptiondrug due to side effects or expense, or a pharmacy mistake.

For example, a care coordination device 106 may initiate a first filltargeting. The first fill targeting may identify members 212 who havenever used a particular drug. The criterion used to identify the members212 in the first fill targeting may include determining if the member212 has used the drug within 360 days of therapy. Other criteria thatmay be used for the first fill targeting may include recent reversalsmade by the member and whether the member was previously identified in arecent first fill targeting.

A case designation may be received at block 904. The case designationmay be received from the patient evaluator manager 402 through thepatient evaluator device 108. The case designation may be provided tothe care coordination device 106 and may be stored in the carecoordinator database 112 as coordination data 122.

A case designation may be an identifier of a case. In some embodiments,each unique case identified by the targeting may be assigned a casedesignation. In some embodiments, the case designation may be assignedby the care coordination subsystem 502. The case designation may providea mechanism to track the case in the disease management carecoordination subsystem 502, so that any entity or affiliate of thedisease management care coordination subsystem 502 may access and trackthe case easily. In some embodiments, a single member 212 may havemultiple case designations. The multiple case designations may representthe multiple member opportunities as identified by the care coordinationsystem. The multiple case designations may be assigned responsive thedifferent disease states of the member 212 or different targets run bythe care coordinator. For example, the care coordinator 204 may run afirst targeting to identify members 212 with high blood pressure andmember A may be listed in the results of the targeting. Member A may beassigned case designation 123. If the care coordinator then runs asecond targeting to identify members with type II diabetes and member Amay be listed in the results of the targeting, then Member A may receivea second case designation 234. Then case designation 123 identifiesMember A as having high blood pressure and case designation 234identifies Member A as having type II diabetes.

The cases and case designations may be transmitted to the healthmanagement vendor device 142. The health management vendor device 142may be used to evaluate the cases. In some embodiments, the healthmanagement vendor 206 may evaluate the cases by using filters orapplying various criteria to the cases to organize or prioritize thereceived case designations.

A case of a member associated with the client 202 may be assigned to apatient evaluator (e.g., the patient evaluator 404) at block 906. Insome embodiments, the patient evaluator manager 402 selects the patientevaluator to be associated with the case. The device (e.g., the carecoordination device 106) then makes the association and stores theassociation in the coordination database 112 as coordination data 122.In some embodiments, the association may be transmitted to the carecoordinator integrated database 132 as integrated data 134. In someembodiments, the patient evaluator device 108 automatically selects thepatient evaluator 208 to be associated with the case. The automaticselection may be based on experience of the patient evaluators 208,background of the patient evaluators 208, caseload of the patientevaluators 208, or the like. A single factor or multiple factors may beused in making the automatic selection.

Using the disease management care coordination subsystem 502, the healthmanagement vendor 206 may assign the cases to patient evaluators 208through a health management vendor device 142. Health management vendorsmay assign cases by member 212 (e.g., all case designations associatedwith member A may be assigned to Patient Evaluator X) or they may assigncases by opportunity type or other criteria (e.g., all case designationsfor diabetic members may be assigned to a diabetic expert). The diseasemanagement care coordination subsystem 502 may transmit the assignmentof the cases to patient evaluators 208 to the care coordinator integratedatabase 132, where parties may access the information with access tothe disease management care coordination subsystem 502 and sufficientprivileges. In some embodiments, a user of the disease management carecoordination subsystem 502, assuming they have sufficient rights andprivileges, may generate a report listing all case designations assignedto a patient evaluator 208, listing all case designations for a member212, or listing all case designations associated with a disease state,member opportunity, or other criterion.

Once a case has been assigned to a patient evaluator, the patientevaluator 208 may have several options. A patient evaluator 208 may loginto the disease management care coordination subsystem 502 to view allthe cases that have been assigned to them. The patient evaluator mayreview each case and take appropriate actions. For instance, the patientevaluator 208 may review a case and determine that the next step may beto contact the member 212. Once the member 212 has been contacted, thepatient evaluator 208 may make a notation in the disease management carecoordination subsystem 502. The notation made by the patient evaluator208 may be transmitted over the network 104 to the care coordinatorintegrated database 132 so that the next person who accesses theinformation associated with the member 212 will have access to thenotations made by the patient evaluator 208.

If the patient evaluator 208 determines that there may be an issue thatneeds specialized care, the patient evaluator may generate an evaluationrequest using the disease management care coordination subsystem 502.For example, if, while the patient evaluator 208 is reviewing a case,the patient evaluator 208 determines that they need further informationfrom a pharmacist, the patient evaluator 208 may generate an evaluationrequest by selecting a button in the disease management carecoordination subsystem 502. The patient evaluator may then send amessage through the disease management care coordination subsystem 502to an available pharmacist regarding the case. In some embodiments, theevaluation request may include the information associated with the case.In some embodiments, the evaluation request may include a note orquestion from the patient evaluator 208 and the case designation.

The evaluation request may be received at block 908. The specialist,healthcare provider, and/or a medical services provider receiving theevaluation request may review the request. The evaluation request mayinclude the case designation. The pharmacist may enter the casedesignation into the disease management care coordination subsystem 502that would then display a comprehensive member profile that may includeclaims history, medical history, lab results, or other type of availableinformation in the disease management care coordination subsystem 502.The healthcare provider or specialist may use the case designation todisplay within the disease management care coordination subsystem 502 toaccess trigger data 122 at block 910.

Trigger data 122 may include any other open case designations associatedwith the member as well as historical case designations that may beaccessed by the disease management care coordination subsystem 502.Evaluation requests may be generated responsive to questions arisingfrom multiple open triggers of a member 212 that may increase thecomplexity of the medical issues of the member 212.

A case designation for a member 212 may indicate that the casedesignation may be a polypharmacy case. The trigger data 122 may be thatthe member 212 is taking eight maintenance drugs concurrently. If apatient evaluator 208 assigned to the case reviews the case anddetermines that they need the assistance of a pharmacist, the patientevaluator generates an evaluation request with a specific question orrequest and the case designation. The pharmacist may receive theevaluation request and the case designation and enters the casedesignation in the disease management care coordination subsystem 502.The disease management care coordination subsystem 502 may display acase designation for a first fill trigger, a case designation formedication adherence, and a case designation for polypharmacy within thepast two months. Thus, the pharmacist would be accessing multipletriggers for a member 212 to evaluate the multiple pharmacyopportunities of the member within the care coordination subsystem 502.

A display may be generated at block 912. The display may be generatedbased on running the targeting, receipt of the query request, and/oraccessing the trigger data 122. In some embodiments, responsive toaccessing 910 trigger data 122, a display may be generated to displaythe patient profile of the current case. In some embodiments, thehistorical case designations are also displayed in the generateddisplay. The historical case designations may be displayed in a separatetab. In some embodiments, other data associated with the member 212 mayalso be displayed in the display, such as the claims data 116 or otherhealth data for the member 212. The generated display may include thelatest information associated with the member 212, such as the latestclaims data 116 or other health data for the member 212, and displayingthe data in a manner that permits the user to utilize the informationwithout being overwhelmed by the volume of information. By generatingdifferent visual aids in the display, such as graphs and charts, theuser may be presented with a great deal of comprehensive informationabout the medical condition of the member 212, related open triggers,and historic medical data.

By providing the pharmacist or any other user of the disease managementcare coordination subsystem 502 with a comprehensive patient profile,the pharmacist and other users may better address the current problemsby understanding the context of the current problem. The diseasemanagement care coordination subsystem 502 may be used to createlinkages between different triggers and case designations. The diseasemanagement care coordination subsystem 502 may be used to document thesteps taken by the pharmacist, patient evaluator, or other use of thedisease management care coordination subsystem 502 after evaluating thepatient profile of the member. For example, the pharmacist, responsiveto the evaluation request and reviewing the patient profile of themember, may communicate with the patient evaluator or directly with themember. Any action taken by the pharmacist, patient evaluator, or otheruser may be documented using the disease management care coordinationsubsystem 502. The documentation of the actions of the users may betransmitted to the care coordinator integrated database 132 so that thenext user may be able to access the updated comprehensive patientprofile of the member 212 to ensure quality treatment for the member212.

In some embodiments, a filter-setting request may be received. Thegeneration of the display may then further receipt of the filter settingrequest.

A case indication of a case may be received from the patient evaluatorat block 914. The case indication may be received from the patientevaluator associated with the case. The case indication may indicatethat the next course of action for the member, notes on the case fromthe patient evaluator, or the like. The case indication may be receivedfrom the patient evaluator through the patient evaluator device 108. Thecase indication may be provided to the care coordination device 106 andmay be stored in the care coordinator database 112 as coordination data122.

A report may be generated at block 916. In some embodiments, the reportmay be an outcomes report. In some embodiments, the report may begenerated based on the coordination data 122. The report may then betransmitted over the network 104 to the client device 102. The generatedreport may include an operational level report, a summary level report,or both the operational level report and the summary level report.

In some embodiments, the integrated data may be readily accessible toany user utilizing the care coordination subsystem 502 and can use theinformation to create linkages in the patient profile of the member andpropose better or different treatment based upon the comprehensivepatient profile. In some embodiments, the integrated and updated datamay be used to generate various levels of reports. In some embodiments,the integrated and updated data may be available as a data feed to oneusers of the care coordination subsystem 502.

One example of the type of reporting available from the subsystem 502may be that if a process change is made, either internally or by ahealth management vendor, the care coordination subsystem 502 maymeasure the result and impact of the change by generating a macro-levelreport of the member population of a client 202.

In some embodiments, the information displayed in the display may becopied. The information may then be pasted into a tool associated withthe client 202.

In some embodiments, criteria may be provided by the patient evaluator208 to the disease management care coordination subsystem 502. Thecriteria may be used to narrow down the results of a query run toprovide applicable cases. The criteria may be displayed in the display.A single criterion or multiple criteria may be used.

FIGS. 10-16 depict example displays according to example embodiments ofthe care coordination subsystem 502. The ovals indicated on FIGS. 12-15indicate the tab of the interface that the screen is displaying. Thedisplays 1000-1600 include example data and may be generated by thedisease management care coordination subsystem 502 and ultimatelypresented to a variety of the users of the system 100. The displays maybe presented via the disease management care coordination subsystem 502.However, other types of displays and modification to the displays1000-1600 may also or alternatively be presented. The displays 1000-1500may be presented to patient evaluators 208 and the displays 1000-1600may be presented to the patient evaluator manager 402. Users of thedisease management care coordination subsystem 502 may be any personassociated with the client 202, care coordinator 204, or healthmanagement vendor 206. Users may include patient evaluators 208 andhealth care professionals 210.

Display 1000, illustrated in FIG. 10, depicts a home screen to a user.The user may select additional tabs to see different content from thehome screen. These tabs include MY CASES tab 1002 and HELP tab 1004. Theuser can also select LOGOUT link 1006 to log out.

Display 1000 may graphically display the status of a number of casesassociated with the user as of a particular date (e.g., doughnut graph1008). In this example, eighty-four cases are pending, fifty-five casesare assigned, and one hundred and twelve cases are unassigned as of Aug.1, 2010. The status may be updated daily (e.g., at midnight), or may beupdated with a different frequency.

Display 1000 may graphically display an information section that maydisplay critical notices or upcoming deadlines for the group (e.g.,Information Section 1012).

Display 1000 may graphically display the number of cases closed by weekas of a particular date (e.g., bar graph 1010). In this example, eightycases were closed during the week of July 11, one hundred and fiftycases were closed during the week of July 18, one hundred and eightycases were closed during the week of July 25, and one hundred and twentycases were closed during the week of August 1. While the prior fourweeks are shown in the display 1000, more or less weeks may be shown.

Once the user selects MY CASES tab 1002 in display 1000, display 1100(depicted in FIG. 11) may be presented to the user. Display 1100 mayinclude a number of sub links that may be selected to view content(depicted in FIGS. 12-15). Displays 1100-1500 respectively show thecontent presented when the VIEW CASES sub link 1102, PATIENT INFO sublink 1202, INVERVENTION sub link 1302, CLAIM HISTORY sub link 1402, andACTIONS sub link 1502 are selected. Other displays besides the display1000 may be the default screen when MY CASES tab 1002 is selected.

The display 1100, shown in FIG. 11, presents the cases associated withthe user to the patient evaluator. The user may perform searches andfiltering by selection of various buttons. The user may also search bycase designation 1104. Through various drop down menus, the users mayfilter by status 1106, list name 1108, intervention 1110, possible use1112, care coordinator ID 1114, and client ID 1116. The user may filterusing other attributes, such as drug information, date created, andother attributes that may be associated with the case designation anddisplayed in the subsystem 502.

Examples of status 1106 may include “A” for assigned, “C” for closed,and “P” for pending. The list name may be defined by the client 202 orotherwise defined. For example, the available list names may includeadvanced, commercial, standard, and express. The drug information andthe creation date may also be presented. In some embodiments, the casesthat have been in the system beyond a certain number of days (e.g.,thirty days, forty five days, sixty days, seventy five days, or ninetydays) may expire and then no longer be presented in the next viewing ofthe display.

In addition, the display 1100 may identify certain members through useof a dollar sign logo (not shown) as being a member that has exceeded acertain dollar threshold for drug cost. The drug cost may be actualdollars spent on various drugs, the ingredient cost of the drug, orotherwise. The amount of the threshold may be adjusted or set by theclient 202, the health management vendor 206, or may be otherwise beadjusted or set. In addition, the amount of spend by a member 212 may betracked on an annual basis, or through a different period of time (e.g.,semiannually). In some embodiments, a number of dollar signs may be usedto indicate a relative level of severity.

Display 1100 may identify certain members as having multiple casesthrough use of an “M” logo 1118. The use of the dollar sign logo and/orthe “M” logo 1118 may be used to identify members with whom contact maybe sought. These members may be considered high risk by the user.

Display 1200 may be presented when PATIENT INFO sub link 1202 isselected. Display 1200 may include information about the member 212including case information 1204, patient information 1206, other opencases 1208 associated with the member 212. Display 1200 may enable theuser to view a more comprehensive profile of the member 212 prior topotential contact. Case information 1204 may include a case designation,intervention type, therapy class, possible use, drug information,diagnosis of the member, medication prescribed to the member, carecoordinator ID, and other information that may be associated with thecase. Patient information 1206 may include the name of the member, dateof birth of the member, age of the member, contact information of themember, address of the member, and other information associated with themember. Other open cases 1208 associated with the member may include atable or other method of organization that includes data related to acase, listed in an organized matter. In some embodiments, each caselisted in the open cases 1208 portion of display 1200 may also include ahyperlink to the case, so that when the hyperlink is clicked by theuser, information associated with the selected case will be displayed bythe care coordination subsystem 502.

Display 1300 may be presented when the INTERVENTION HISTORY sub link1302 is selected. Display 1300 may present information aboutintervention actions or contact made by the user or other users with themember. The information displayed to the member in display 1300 includescase information 1204, as described above. Display 1300 may display anIntervention History 1308 that may include Case Designations of casesassociated with the client for intervention, List Name, Intervention,Therapy Class, Possible Use, Drug Name, Case Worker (e.g. patientevaluator), Care Coordinator ID, and Client ID. Sections for caseoutcomes 1304 and case note history 1306 may also be included in display1300. The case outcomes 1304 section may display information related toactions and outcomes taken concerning the member. In some embodiments,the case outcomes 1304 may display information from the interventionhistory and cases listed in the intervention history. The case notehistory 1306 section of display 1300 may include notes entered by apatient evaluator assigned the case, including dates and times actionswere taken related to the case.

Display 1400 may be presented when CLAIMS HISTORY sub link 1402 isselected. The information displayed to the member in display 1400 mayinclude case information 1204, as described above. The claims historysection 1404 of display 1400 may include a table or other organizationstructure containing historic claims data for the member displayed tothe user. The example information presented to the user in the display1400 includes fill date, pharmacy, NABP, drug information, quantity, daysupply, physician, therapy class, and possible use.

After reviewed of appropriate displays, the user may be ready to take anaction and document the action taken through display 1500. Display 1500may thus be presented when ACTIONS sub link 1502 is selected. Theinformation displayed to the member in display 1500 may include caseinformation 1204, as described above.

Display 1500 may include an ACTIONABLE OPTIONS section 1504. The carecoordinator subsystem 502 may generate a list of actions taken anddisplay them in the ACTIONABLE OPTIONS section 1504 of display 1500. Theuser may select one or more actions displayed in the ACTIONABLE OPTIONSsection 1504 of display 1500. The example actions presented to the userin display 1500 may include, but are not limited to: consulted with MD,consulted with pharmacist, consulted with pharmacist for lower costalternative, discussed medication side effects that may be leading tonon-adherence (e.g., failing to refill a prescription drug), identifiedreason for non-adherence, medication was discontinued or changed, memberis post-hospital discharged, member is unavailable, member refused tospeak with nurse, recommended a fix or removal of an adherence barrier,referred to external resource, referred to internal resource, referredto pharmacist for medication review, reviewed cases (e.g., as reviewedby Express Scripts, Inc. in accordance with its services offered underthe ExpressAlliance™ brand), reviewed medications with the member,reviewed prescription claim history of the member, and sent letter tothe member. The user may select (e.g., by selecting a click box) oneaction or multiple actions from the display.

Display 1500 may include a CHANGE STATUS TO section 1506. The CHANGESTATUS TO section 1506 may include options that enable the user tochange the status of a new or existing action. In some embodiments, theoptions may include ASSIGNED, PENDING, or CLOSED.

Display 1500 may include a NOTES section 1508. In some embodiments, theNOTES section 1508 may be enabled only if in the CHANGE STATUS TOsection 1506 has the option PENDING selected. The NOTES section 1508 maybe used to enter an explanation as to why an action is PENDING. In someembodiments, the NOTES section 1508 may always be enabled and permit theuser to add any notes regarding the case. The user may also review notehistory and enter a current note. The user can also return the case to acase manager (e.g., the patient evaluator manager 402) using the RETURNTO CASE MANAGER option 1510.

When the user is a manager of other users (e.g., the patient evaluatormanager 402), the user may use display 1600 to assign cases to otherusers.

The display 1700 is an example display for polypharmacy. The display1700 presents a graphical chart to the user of the amount of drug use bythe member in the care coordination subsystem 502. The polypharmacygraphic 1700 may be displayed in the care coordination subsystem 502 ina separate tab or within one of the above-mentioned displays. Thegraphical chart 1700 may enable the user to determine the drug burden onthe member and whether the user should consider a change in themedications used by the member.

The example polypharmacy information shown in display 1700 includestherapy classes, possible users, drugs, and a time period. The timeperiod includes the quantity of drugs in the fill and the manner inwhich the drugs were filled (e.g., retail or mail order).

FIG. 18 shows a block diagram of a machine in the example form of acomputer system 1800 within which a set of instructions may be executedcausing the machine to perform any one or more of the methods,processes, operations, or methodologies discussed herein. The clientdevice 102, the care coordination device 106, and/or the patientevaluator device 108 may include the functionality of the one or morecomputer systems 1800.

The disease management care coordination subsystem 502 may include toolsto further facilitate communication and maximize best practices betweenorganizations. In some embodiments, a workforce management function maybe included. Individual targets supplied by the healthcare coordinatormay be loaded into the disease management care coordination subsystem502 for review by users (e.g., health management vendors, nurses,clients, health care professionals). The targets may be sorted usingvarious clinical and operational filters. An example of a clinicalfilter may be sorting a target by disease state or age. An example of anoperational filter may include monetary or pharmacy claims, thresholdsor multiple concurrent cases. Both filters may be driven by an indicatorthat may be derived from the target data within the disease managementcare coordination subsystem 502. These may include slide filters andsearches and assignment of cases.

In some embodiments, the ability to sort cases by Customer DefinedCriteria called a Watch List may be included. Common methods to sorttargeted members by the healthcare coordinator may include Member ID,Disease State, or by healthcare coordinator targets. Many healthcaremanagement vendors (e.g., disease management vendors) may use bothpharmacy and medical claims information in their choice to message asick member. Other user may prefer to message members by location or usealternative criterion that may not be sortable using healthcarecoordinator systems. The Watch list may be a cross reference fileconsisting of a healthcare coordinator identifier, a customer definedidentifier, and a free text field that may be loaded into the healthcare coordinator system by the customer. As long as the healthcarecoordinator identifier and at least one alternative field is populated,the system may assign these values to the healthcare coordinatortargeting for viewing and sorting within the subsystem 502. This maypermit the users in different organizations to continue to use theirnormal/desired processes of selecting members to message when evaluatingthe healthcare coordinator targets and improve efficiency and carecoordination.

In some embodiments, polypharmacy and pill burden representedgraphically. The polypharmacy graph may groups like drugs in therapyclasses into categories and map fills by retail and mail order over a120-day period. Visual representation of drug fills may enable users toidentify wasteful polypharmacy and potential changes in therapy and gapsin care. A calculation for pill burden may be displayed either in or inconjunction with the polypharmacy graph to identify the severity of thepolypharmacy.

The disease management care coordination subsystem 502 may providefeatures related to medical home. Medical home, which may also be knownas the patient-centered medical home (PCMH) may be a health care settingthat facilitates partnerships between individual members, their personalproviders, and when appropriate, the family of the member. Medical homeis an approach to providing comprehensive primary care to members. Amedical home may associate the member with a core group of doctors or adoctor, rather than having the member visit multiple doctors fordifferent symptoms. Medical home reduces the fractionalized care thatmay result from a member receiving care from multiple doctors who arenot in coordination with each other. The medical home feature of thesubsystem 502 may provide the healthcare provider with information fortheir member population. The healthcare provider may then identify amember and can identify whether the member is receiving care fromanother health care provider by accessing data associated with themember, such as claims information.

In some embodiments, the disease management care coordination subsystem502 may include case tracking and reporting features. Users may have theability to change the status of cases so the progress may be monitoredfrom start to finish within the disease management care coordinationsubsystem 502. Closed cases, custom actions and notes entered by theuser may be made available both in the case history of the member forlater review as well as in summary and outcomes reporting. Additionalreports using a multi-factorial method to evaluate member risk may beused and may be based on key pharmacy factors that contribute topharmacy complications of a member. Drug spend, concurrent openhealthcare coordinator cases, pill burden threshold (e.g., average pillsconsumed greater than ten per day) and predictive adherence risk scoresfor Hypertension, Diabetes and Cholesterol may be combined to create atotal risk score. This report may enable users to identify memberpopulations that require the most attention and care.

The disease management care coordination subsystem 502 may providemeasurement tools for members. One example of a measurement tool is amedication possession ratio (MPR). The MPR uses the historical usagedata of a particular drug and measures the percentage of time that amember took the medication. If the MPR falls below a certain threshold,the member may be categorized as non-adherent with the medication, whichmay identify that the member may be at risk. The care coordinationsubsystem 502 may generate several predictive model score for a member.The predictive model scores may be associated with drugs consumed by themember or disease states of the member. The predictive model scores maypredict the potential future risk of the member. The different between ameasurement tool, such as the MPR and the predictive model score is thatthe MPR is inherently a historical calculation, wherein the calculationis based upon historic data of the member. The predictive model scoreinstead may use the claims history of the member and forecasts potentialfuture risk for the member. Both types of tools may be displayed in thecare coordination subsystem 502. By providing the predictive modelscore, which may be applied to various trigger data 122 of the member,the disease management care coordination subsystem 502 may provide theability to quickly triage and prioritize members, to target members andtrack the progress of their actions throughout the disease managementcare coordination subsystem 502. The predictive model score may providea more efficient way to address healthcare issues sooner.

Another measurement tool is pill burden. Pill burden is the number ofpills that a member should consume in a day. In some cases, the higherthe pill burden, the more likely members are to be non-adherent to theirmedication. A high pill burden may also lead to complications in druginteractions for the member and may reduce the effectiveness of the drugor give rise to unwanted side effects.

Combining the predictive modeling scores, triggers and measurementstools for open cases may enable users of the disease management carecoordination subsystem 502 to evaluate members to assess their healthrisks. Using a variety of measurement tools and triggers may help usersmore efficiently triage and prioritize members and facilitate casemanagement.

The disease management care coordination subsystem 502 may generatepost-predictive model processing-aggregate scores for an individualusing the output of the predictive modeling scores. In some embodiments,the disease management care coordination subsystem 502 may take all thepredictive modeling scores associated with a member and manipulate thescores to generate a post-predictive model processing-aggregate scorefor a member. In some embodiments, the tool may take the median or theaverage of all the scores associated with the member. In someembodiments, the disease management care coordination subsystem 502 maytake the average of a number of the lowest or highest values of thepredictive modeling tools.

Responsive to generating the post-predictive model processing-aggregatescores for a member, the disease management care coordination subsystem502 may display the score to a user of the system. The user may reviewthe score and adjust the healthcare provided to the member based on thegenerated score. In some embodiments, the score may be used to target acertain population of the member population to prioritize high-riskmembers. In some embodiments, the score may be used to tailor thehealthcare treatment being received by the member.

In some embodiments, the disease management care coordination subsystem502 may provide security to safeguard patient health information, knownin the industry as Protected Health Information. In some embodiments,lists may be created to restrict access to patient data, reports andfunctions at login. Members may be added or deleted to the lists byrequest to individuals with proper permissions. In some embodiments, theProtected Health Information of a patient may be managed by a differentdatabase or module.

In an example embodiment, the machine operates as a standalone device ormay be connected (e.g., networked) to other machines. In a networkeddeployment, the machine may operate in the capacity of a server or aclient machine in server-client network environment, or as a peermachine in a peer-to-peer (or distributed) network environment. Themachine may be a server computer, a client computer, a personal computer(PC), a tablet PC, a set-top box (STB), a Personal Digital Assistant(PDA), a cellular telephone, a web appliance, a network router, switchor bridge, or any machine capable of executing a set of instructions(sequential or otherwise) that specify actions to be taken by thatmachine. Further, while only a single machine is illustrated, the term“machine” shall also be taken to include any collection of machines thatindividually or jointly execute a set (or multiple sets) of instructionsto perform any one or more of the methodologies discussed herein.

The example computer system 1800 includes a processor 1812 (e.g., acentral processing unit (CPU) a graphics processing unit (GPU) or both),a main memory 1804 and a static memory 1806, which communicate with eachother via a bus 1808. The computer system 1800 may further include avideo display unit 1180 (e.g., a liquid crystal display (LCD) or acathode ray tube (CRT)). The computer system 1800 also includes analphanumeric input device 1812 (e.g., a keyboard), a cursor controldevice 1814 (e.g., a mouse), a drive unit 1816, a signal generationdevice 1818 (e.g., a speaker) and a network interface device 1820.

The drive unit 1816 includes a computer-readable medium 1822 on which isstored one or more sets of instructions (e.g., software 1824) embodyingany one or more of the methodologies or functions described herein. Thesoftware 1824 may also reside, completely or at least partially, withinthe main memory 1804 and/or within the processor 1812 during executionthereof by the computer system 1800, the main memory 1804 and theprocessor 1812 also constituting computer-readable media.

The software 1824 may further be transmitted or received over a network1826 via the network interface device 1820.

While the computer-readable medium 1822 is shown in an exampleembodiment to be a single medium, the term “computer-readable medium”should be taken to include a single medium or multiple media (e.g., acentralized or distributed database, and/or associated caches andservers) that store the one or more sets of instructions. The term“computer-readable medium” shall also be taken to include any mediumthat is capable of storing or encoding a set of instructions forexecution by the machine and that cause the machine to perform any oneor more of the methodologies of the present invention. The term“computer-readable medium” shall accordingly be taken to include, butnot be limited to, solid-state memories, and optical media, and magneticmedia.

Certain systems, apparatus, applications or processes are describedherein as including a number of modules. A module may be a unit ofdistinct functionality that may be presented in software, hardware, orcombinations thereof. When the functionality of a module is performed inany part through software, the module includes a computer-readablemedium. The modules may be regarded as being communicatively coupled.

The inventive subject matter may be represented in a variety ofdifferent embodiments of which there are many possible permutations.

In an example embodiment, a method for disease management carecoordination may include integrating claim data associated with aprescription drug with additional health data from a plurality of datafeeds received from a client device, a care coordination device, and ahealth management vendor device. The integrated data may be targeted toidentify a member. The integrated data associated with the member may betransmitted to a patient evaluator device. The integrated data may beupdated using additional member information received from the patientevaluator device.

In an example embodiment, a non-transitory machine-readable mediumcomprising instructions, which when executed by one or more processors,may cause the one or more processors to perform the followingoperations: integrating claim data associated with a prescription drugwith additional data from a plurality of data feeds received from aclient device, a care coordination device, and a health managementvendor device; targeting the integrated data to identify a member;transmitting the integrated data associated with the member to a patientevaluator device; and updating the integrated data using additionalmember information received from the patient evaluator device.

In an example embodiment, a system may include a processor; a memorycoupled to the processor; an integration module deployed in the memoryand executed by the processor to integrate claim data associated with aprescription drug with additional health data from a plurality of datafeeds received from a client device, a care coordination device, and ahealth management vendor device; a targeting module deployed in thememory and executed by the processor to target the integrated data toidentify a member; an integrated data transmission module deployed inthe memory and executed by the processor to transmit the integrated dataassociated with the member to a patient evaluator device; and anintegrated data update module deployed in the memory and executed by theprocessor to update the integrated data using additional memberinformation received from the patient evaluator device.

In an example embodiment, targeting is run on the claims data using thetargeting data. An evaluation request is received. A display may begenerated based on running the targeting and receipt of the queryrequest. Additional methods and systems are disclosed.

Thus, methods and systems for disease management care coordination havebeen described. Although embodiments of the present invention have beendescribed with reference to specific example embodiments, it will beevident that various modifications and changes may be made to theseembodiments without departing from the broader spirit and scope of theembodiments of the invention. Accordingly, the specification anddrawings are to be regarded in an illustrative rather than a restrictivesense.

The term “based on” or using, as used herein, reflects an open-endedterm that can reflect others elements beyond those explicitly recited.

Certain systems, apparatus, applications or processes are describedherein as including a number of modules. A module may be a unit ofdistinct functionality that may be presented in software, hardware, orcombinations thereof. When the functionality of a module is performed inany part through software, the module includes a computer-readablemedium. The modules may be regarded as being communicatively coupled.

The inventive subject matter may be represented in a variety ofdifferent embodiments of which there are many possible permutations.

The methods described herein do not have to be executed in the orderdescribed, or in any particular order. Moreover, various activitiesdescribed with respect to the methods identified herein can be executedin serial or parallel fashion. Although “End” blocks are shown in theflowcharts, the methods may be performed continuously.

The Abstract of the Disclosure is provided to comply with 37 C.F.R.§1.72(b), requiring an abstract that will allow the reader to quicklyascertain the nature of the technical disclosure. It is submitted withthe understanding that it will not be used to interpret or limit thescope or meaning of the claims. In addition, in the foregoing DetailedDescription, it can be seen that various features are grouped togetherin a single embodiment for the purpose of streamlining the disclosure.This method of disclosure is not to be interpreted as reflecting anintention that the claimed embodiments require more features than areexpressly recited in each claim. Rather, as the following claimsreflect, inventive subject matter may lie in less than all features of asingle disclosed embodiment. Thus, the following claims are herebyincorporated into the Detailed Description, with each claim standing onits own as a separate embodiment.

What is claimed is: 1-45. (canceled)
 46. A method comprising:determining, on a computer processor, for each of a plurality ofopportunity-available members a prescription drug spend, a number ofconcurrent open healthcare coordinator cases, and a pill burdenthreshold; calculating, on the computer processor, for each of theplurality of opportunity-available members a predicted adherence riskscore for a disease state; calculating, on the computer processor, atotal risk score for each of the plurality of opportunity-availablemembers based on the prescription drug spend, the number of concurrentopen healthcare coordinator cases, the pill burden threshold, and thepredicted adherence risk score for the disease state; selecting, on thecomputer processor, a high risk member portion among the plurality ofopportunity-available members based on the total risk score for each ofthe plurality of opportunity-available members; transmitting, on thecomputer processor, integrated data associated with the high risk memberportion of the plurality of opportunity-available members to a patientevaluator device, the patient evaluator device associated with a patientevaluator; updating, on the computer processor, the integrated dataassociated with a plan member using additional member informationtransmitted by the patient evaluator device to create updated integrateddata, the additional member information including documentation ofclinical outreach performed on the plan member by the patient evaluator,the plan member being among the high risk member portion of theplurality of opportunity-available members; and generating, on thecomputer processor, a report reflecting patient evaluator outreachresults based on the updated integrated data.
 47. The method of claim46, further comprising: accessing targeting data including a pluralityof clinical-defined queries; and running the plurality ofclinical-defined queries on population integrated data to identify theplurality of opportunity-available members as having an opportunity forclinical outreach, the population integrated data including theintegrated data associated with the plan member.
 48. The method of claim47, wherein running the plurality of clinical-defined queries on theintegrated data associated with the member identifies a plurality ofplan members having an opportunity for clinical outreach, the pluralityof plan members including the plan member, wherein transmitting theintegrated data associated with the plan member includes transmittingthe integrated data associated with the plurality of plan members to thepatient evaluator device, the method further comprising: receivingmember identification of the plan member from the patient evaluatordevice, wherein updating the integrated data associated with the planmember is based on receipt of the member identification.
 49. The methodof claim 47, wherein a clinical-defined query of the plurality ofclinical-defined queries includes patient-inclusive criteria,patient-exclusive criteria, or both patient-inclusive criteria andpatient-exclusive criteria for member identification.
 50. The method ofclaim 46, further comprising: creating the integrated data associatedwith the plan member by associating prescription drug claim data of theplan member of a pharmacy benefit plan with additional health data ofthe plan member from a plurality of data feeds received from a clientdevice associated with a plan client of a pharmacy benefit manager, acare coordination device associated with a care coordinator thatfacilitates communication among a plurality of healthcare entities toaddress population pharmacy issues on behalf of the plan client, and ahealth management vendor device associated with a health managementvendor.
 51. The method of claim 46, further comprising: associating theplan member with a case designation based on identification of the planmember as having an opportunity for clinical outreach; and assigning thecase designation to the patient evaluator among a plurality of availablepatient evaluators.
 52. The method of claim 49, wherein assignment ofthe case designation is based on relative experience of the plurality ofavailable patient evaluators, background of the plurality of availablepatient evaluators, case load of the plurality of available patientevaluators, or combinations thereof.
 53. The method of claim 46, furthercomprising: receiving an evaluation request from the patient evaluatordevice, the evaluation request identifying the plan member to beevaluated by the patient evaluator; transmitting a patient profile tothe patient evaluator device, the patient profile including trigger dataand the integrated data associated with the plan member; updating thepatient profile using information received from the patient evaluatordevice; and generating a response to the evaluation request based onupdating the patient profile.
 54. The method of claim 46, furthercomprising: receiving the additional member information from the patientevaluator device, wherein updating the integrated data is based onreceipt of the additional member information.
 55. The method of claim46, wherein a member population of the plan client includes theplurality of opportunity-available members and a plurality of additionalmembers.
 56. A non-transitory machine-readable medium comprisinginstructions, which when executed by one or more processors, cause theone or more processors to perform the following operations: determinefor each of a plurality of opportunity-available members a prescriptiondrug spend, a number of concurrent open healthcare coordinator cases,and a pill burden threshold; calculate for each of the plurality ofopportunity-available members a predicted adherence risk score for adisease state; calculate a total risk score for each of the plurality ofopportunity-available members based on the prescription drug spend, thenumber of concurrent open healthcare coordinator cases, the pill burdenthreshold, and the predicted adherence risk score for the disease state;select a high risk member portion among the plurality ofopportunity-available members based on the total risk score for each ofthe plurality of opportunity-available members; transmit integrated dataassociated with the high risk member portion of the plurality ofopportunity-available members to a patient evaluator device, the patientevaluator device associated with a patient evaluator; update theintegrated data associated with a plan member using additional memberinformation transmitted by the patient evaluator device to createupdated integrated data, the additional member information includingdocumentation of clinical outreach performed on the plan member by thepatient evaluator, the plan member being among the high risk memberportion of the plurality of opportunity-available members; and generatea report reflecting patient evaluator outreach results based on theupdated integrated data.